All Smiles

A fluorescent ceiling light flickers, and three pairs of young eyes dart nervously upward. The students shift uneasily in their seats, waiting for the Lord Stirling Community School nurse to call their names. One child crosses her arms, frowning deeply. Another tugs his teacher’s hand until she lets him snuggle into the crook of her arm.

One curious little boy waiting for a Band-Aid stares across the nurse’s office toward a mysterious, boxlike room in the back. Inside is a low, reclining blue chair and a portable X-ray machine. Painted on a wall is a multicolored mural of three happy little teeth running toward the school entrance, greeted by a smiling tube of toothpaste.

“What’s in there?” the boy asks a hygienist standing in the nurse’s office.

“That’s our dental office,” she replies, as the school nurse hands her boxes of toothpaste.

“You fix our teeth in there?” the boy asks.

“Yes, we sure do,” she says, nodding.

For students in New Brunswick, New Jersey, the in-school dental office, which opened at Lord Stirling in late fall, is still very much a curiosity. Dr. Ping Cai, one of two dentists who work part time at the 700-student elementary school, says pupils constantly stop her in the hall to ask when they can visit.

But school nurses and educators insist the dental office is much more than a curiosity. After observing students who couldn’t concentrate because of toothaches or cried constantly because their teeth were literally rotting, they say it is filling a huge void for a school in which roughly 70 percent of the students live below poverty level.

"[Dental care is] not something we can ignore,” says Delfos Bruno, Lord Stirling’s vice principal. “We need to teach a healthy child. The problem is, we have been taught that dental care is a luxury, and it’s not. It’s a total necessity.”

This past November, New Brunswick’s 7,000-student district opened two school-based dental offices with the help of local donations, as well as a $105,000 grant from Delta Dental, a nonprofit organization based in Oak Brook, Illinois, that offers nationwide dental insurance. By the time five new schools are built at the end of the 2003-04 school year, each will have a dental suite.

Targeting students without dental insurance, the in-school clinics offer screenings, X-rays, sealants, and fillings. Each facility contains a full dental suite and is staffed by a dental hygienist and two part-time dentists, who also venture into classrooms to stress the importance of oral health.

“This program has been a long time in coming,” says Betty Whalen, the district’s director of health. “My family was poor, and when there’s a choice between a roof over your head and a child’s teeth,it comes down to priorities. There’s a real need forth is here.”

Although Whalen experienced the disadvantages of poor dental care firsthand, the severity of the problem didn’t really hit home until she visited classrooms. “I used to dress up as the Cat in the Hat every year,” she says. “I’d ask the kids, ‘How many of you have toothbrushes?’ And then I’d hand out toothbrushes to the ones who needed them. Well, I gave a toothbrush to this one little boy, and his eyes got really big and he said, ‘Wow, now I won’t have to share a toothbrush with my brother.’ I’d never thought about sharing a toothbrush before. That really got me.”

The U.S. Department of Health and Human Services has described dental disease as a “silent epidemic.” Tooth decay affects nearly 50 percent of 1st graders and about 80 percent of 17-year-olds, and an estimated 51 million school hours are lost each year due to dental-related illnesses, according to a report released in 2000 by the U.S. surgeon general. The report also estimated that children living in poverty are twice as likely as other youngsters to suffer from tooth decay and that about 25 percent of poor children have never seen a dentist by the time they reach kindergarten.

Still, making dental care accessible to students is easier said than done. With equipment costs alone ranging from $30,000 to $50,000 for a one-chair dental suite, the major obstacle is funding. “It is a financial problem to do this,” says Whalen, who is working toward paying for the New Brunswick program through federal and state grants. The district also hopes to obtain a three-year, $500,000 grant from a health care philanthropy.

At many schools, finding space as well as dentists that districts can afford to pay are the other major hurdles. At Lord Stirling, the doctors paid about $45 an hour, but most want much higher rates. What’s more, many are unwilling to work with children, Whalen says. The United States has more than 175,000 dentists, but only 3,800 work in pediatrics, according toDr. Burton L. Edelstein, a spokesman for the Chicago-based American Academy of Pediatric Dentistry. To complicate matters, for every three practitioners who retire each year, only two graduate to replace them.

But there is hope. Several companies including Johnson & Johnson and Colgate donate toothbrushes, toothpaste, and other dental supplies to school programs. And dentists in private practice account for more than $1.5 billion in charity services each year.

Many educators say that school-based programs help improve student achievement, bridge cultural gaps, and improve children’s self-image. But critics like Lance Izumi, director of the Center for School Reform at the Pacific Research Institute, a San Francisco-based think tank, contend that such care puts an unrealistic financial burden on schools and detracts from their true mission: educating students.

“I think there is validity to the argument that a child feeling pain will not do as well [in school],” acknowledges Izumi, “but while we need to ensure health care for our children, that doesn’t mean that health care should be in schools.”

Focusing on teeth, he argues, could have a serious impact on schools that are already struggling to find enough money to buy textbooks and pay teachers. “It seems absurd to me that you would add on a whole layer of services that schools need to administer when they can’t administer what they need to now,” Izumi says. “You’re just setting up [the system] for failure.”

Public health experts point to different ways that schools can offer services to students. Dr. Ron Elliot, a dentist and the director of dental services with the Jefferson County, Alabama, health department, says that his agency and the 40,000-student county school district have run a successful mobile dental program since the early 1950s.

The district has three vans that contain full dental suites. Each is open five days a week, eight hours a day, and offers just about every service except major oral surgery. The program, which serves 30 schools and between 7,500 to 10,000 students a year, is financed with local tax dollars.

Instead of offering in-house care, school-linked programs screen and refer students to community dental clinics and providers. Dr. Edelstein of the American Academy of Pediatric Dentistry has worked with both school-based and school-linked programs in the Washington, D.C., area. He says school-linked services are probably a better option for most districts because programs housed in individual schools areoften too small to be cost- effective.

The question can be one of demand, adds Jane Shapiro, the community health coordinator with the Cheshire Medical Center in Keene, New Hampshire, which runs a free school-linked program financed by the Cheshire Health Foundation. The program, which has been in place since 1997, offers cleanings,fluoride treatments, and oral education to pupils in kindergarten through 3rd grade. In 2001-02, the program screened more than 1,300 students. A school-based program would not be practical in Keene, Shapiro says, because of the community’s size.

In New Brunswick, however, Betty Whalen and her staff are convinced that an in-school clinic is the way to go. “I think it’s important that people see that you can do this,” she says. “You need alot of commitment and support from parents, staff, and nurses. Maybe you even need to be a littlebit crazy, but my goal is to keep this program going.”

Eight-year- old Brittney Marmolejos will be happy to hear that. The Lord Stirling 3rd grader used to be terrified of going to the dentist. When Brittney was an infant, her mother says, a dentist had to grind down her two front baby teeth to the gum line to save her primary teeth from succumbing to severe oral decay. Now, Brittney is all smiles when it comes to her teeth, largely because her current dentist works at her school.

“Here is better,” Brittney says, “because theydo the work soft, not hard. You feel happy about seeing the dentist.”